Complete the questionnaire & receive a complimentary telephone consultation.
Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?
Do you frequently have pains in your chest when you perform physical activity?
Have you had chest pain when you were not doing physical activity?
Do you lose your balance due to dizziness or do you ever lose consciousness?
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program? (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)
Are you pregnant now or have given birth within the last 6 months?
Have you had a recent surgery?
If you have marked YES to any of the above, please elaborate below:
Do you take any medications, either prescription or non-prescription, on a regular basis?
What is this medication for?
How does this medication affect your ability to exercise or achieve your fitness goals?
Height
Weight (Pounds)
Chest Size (Measure across nipple line)
Waist (Measure through belly button)
Hips (Measure at widest part)
Right Thigh (Measure just below the gluteal fold)
Right Calf (Measure at widest part)
Where do you carry any excess weight? (If applicable).
Do you have any muscular imbalances? For example, are you stronger on one side than another.
Do you smoke?
If yes, how many?
Do you drink alchohol?
If yes, how many glasses per week?
How many hours do you regularly sleep at night?
Describe your job:
On a scale of 1-10, how do you rate your stress level?
List your biggest sources of stress:
Is anyone in your family overweight? Check all that apply:
Have you ever been overweight?
If yes, at what age(s)?
When were you in the best shape of your life?
Have you been exercising consistently for the past 3 months?
When did you first start thinking about getting in shape?
What if anything stopped you in the past?
On a scale of 1-10, how would you rate your present fitness level?
List previous or current exercise programs. Example: strength training, free weights, assisted programs.
Do you actively participate in sports?
If yes, which sports?
On a scale of 1-10, how would you rate your Nutrition?
How many times a day do you usually eat (including snacks)?
Do you skip meals?
Do you eat breakfast?
Do you eat late at night?
What activities do you engage in while eating?
How many glasses of water do you consume daily?
Do you feel drops in your energy levels throughout the day?
If yes, when?
Do you know how many calories you eat per day?
Are you currently or have you ever taken a multivitamin or any other food supplements??
If yes, please list the supplements:
At work or school, do you usually:
How many times per week do you eat out?
Do you do your own grocery shopping?
Do you do your own cooking?
Besides hunger, what other reason(s) do you eat?
Do you eat past the point of fullness?
Realistically, how much time would you like to spend during each exercise session?
What days would you prefer to exercise?
What equipment do you own: Examples: dumbells, barbells, treadmill, yoga ball, etc...
How can a Personal Trainer help you?
What are the fitness goals you would like to achieve in the next 3-12 months?
How will you know you've achieved these goals?
Where do you rate health in your life?
How committed are you to achieving your fitness goals?
What do you think are the most important things your Personal Trainer can do to help you achieve your fitness goals?
